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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address } ' ' <br /> 6 y 'r' c---�( �_.. City ,���(L!'L Lot Size L� C PM <br /> Owner's Name Address' g3 3 F6 cy <br /> Phone <br /> F Contractor/*� 4 Address 6- 6K 1Q��rJa 4- L C <br /> License No. V1,930 Phone j <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER Cl <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES' DISPOSAL FLO. PROP. LINE l <br /> _ l <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA 'CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca'` ' . Dia:'of Well Excavation �Dia. of Well Casing <br /> VQ <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Trac -,-TypeFf <br /> Y ,� of Casing Specifications-�f ',�L S <br /> ❑ Public L1 Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation ,Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction 1-1ellDiameter Sealing Material (top 501 <br /> Depth— ' - Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION KDESTRUCTION ❑ (No septic system permitted if public sewer is ' <br /> Installation will serve: Residence Commercial_ Other available within 200 feet.) <br /> Number of living units: IL— Number of bedrooms <br /> Character of soil to a depth of 3 feet! <br /> Water table depth S <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments r <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> . <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE No. & Length of lines a ;TotaLlerigth/size <br /> FILTER BEDNip -+ �-r <br /> ❑ Distance to nearest: well b 6 Foundation S�ti, roperiy Line <br /> rill <br /> SEEPAGE PITS ❑ Depth Sii r.. <br /> ze Number. `1 <br /> SUMPS fK Distance to nearest:. Well/12-0,L+--Foundation �a r">�Property Line e-1X, ., p <br /> DISPOSAL PONDS ❑ <br /> hereby certify that I have prepared this application°and that the work will be done din accordance with San.- in county ordinances,state laws, and I <br /> rules and regulations of the San Joaquin Local Healtli DistrictF.,.,._.. �, <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring�or.sub-irontracting signature <br /> certifies the following: "I certify,.that in the performance of the work for which t his permit is issued, I shall employ persons subjecrico workman's compensa- <br /> tion laws of Califo nia." <br /> The applicant m t II for all requir <br /> e <br /> d inspections. Complete drawing on reverse side. 7:,VJ <br /> Signed X Tit Date: <br /> FOR DEPARTMENT USI ONLY <br /> Application Accepted by r DateW- 0, <br /> Area. 13 <br /> Pit or Grout Inspection by pa ( �Final Iynspection byP DateAdditional Comments: ,• w <br /> Lodi- 3621 -. ❑ NFentrca-*23 7i -- ❑ Tracy r 635-6385f =`- <br /> ^* -�-• .---, - ,,,.-,_a - - <br />"r� Applicant - Return all copies to: Environmental Health PermitkServices 3601 E. Hazelton Ave.;-.P:O. Box 2009, StO.,CA 95201 J` <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. <br /> INFO 7L y, 4 Qui D G J <br /> -+,EH14-281RE+%:'t7asl �Y ­7(' SUV -©{.Uf� '�' L��D� ..-3Z-q 1 <br /> i <br />